title: Surgical outcome following decompressive craniectomy for poor-grade aneurysmal subarachnoid hemorrhage in patients with associated massive intracerebral or Sylvian hematomas.
abstract: BACKGROUND
  Patients with poor-grade aneurysmal subarachnoid hemorrhage (SAH) presenting with large intracerebral (ICH) or sylvian hematomas (SylH) have poor outcomes due to the mass effect of significant brain stem compression following mass effect. On the other hand, decompressive craniectomy (DC) can reduce morbidity and mortality in critically ill patients with massive ischemic infarction and severe head injury. However, the role of DC in SAH patients is not fully understood. We investigated the outcome of DC in poor-grade SAH presenting with large ICH or SylH.
  
  
  METHODS
  110 consecutive patients with poor-grade SAH (Hunt & Kosnik (H&K) grades IV and V, and Fisher group 4) were admitted to our hospital between April 1, 1993, and July 30, 2004. We treated 57 of those who presented with large ICH or SylH using DC. We retrospectively reviewed medical charts, radiological findings, operative notes, and video records.
  
  
  RESULTS
  Among the 57 patients (mean age 57.8, male 29, female 28), 25 were classified as H&K grade IV and 32 as grade V. Ruptured aneurysms were located on the internal carotid artery in 11 and the middle cerebral artery in 46 patients. 50 of the aneurysms were small, 5 were medium, and 2 were large. Rerupture was preoperatively confirmed in 13 (22.8%). Hypothermia was applied to 17 (29.8%). The Glasgow Outcome Scale on discharge showed good recovery, moderate recovery, severe disability, vegetative state, and death in 8 (14.0%), 13 (22.8%), 16 (28.1%), 8 (14.0%), and 12 (21.1%), respectively. The outcomes of grade IV patients were favorable and poor in 14 (56.0%) and 10 (40.0%), respectively, and 1 (4.0%) died.
  
  
  CONCLUSIONS
  Several experimental studies have also indicated that DC significantly improves outcome due to reduced intracranial pressure or increased perfusion pressure. Urgent DC for poor-grade SAH with space-occupying hematoma can lead to survival with good recovery in some patients.
authors.affiliation: Department of Neurosurgery, National Hospital Organization Disaster Medical Center, Tokyo, Japan. naotani@tdmc.hosp.go.jp
authors.forename: Naoki
authors.initials: N
authors.lastname: Otani
authors.forename: Yoshio
authors.initials: Y
authors.lastname: Takasato
authors.forename: Hiroyuki
authors.initials: H
authors.lastname: Masaoka
authors.forename: Takanori
authors.initials: T
authors.lastname: Hayakawa
authors.forename: Yoshikazu
authors.initials: Y
authors.lastname: Yoshino
authors.forename: Hiroshi
authors.initials: H
authors.lastname: Yatsushige
authors.forename: Hiroki
authors.initials: H
authors.lastname: Miyawaki
authors.forename: Kyoko
authors.initials: K
authors.lastname: Sumiyoshi
authors.forename: Aoyagi
authors.initials: A
authors.lastname: Chikashi
authors.forename: Satoru
authors.initials: S
authors.lastname: Takeuchi
authors.forename: Goh
authors.initials: G
authors.lastname: Suzuki
mesh_terms: D000368:Aged; D017542:Aneurysm, Ruptured / Q000150:complications / Q000000981:diagnostic imaging / Q000601:surgery*; D001925:Brain Damage, Chronic / Q000453:epidemiology / Q000209:etiology / Q000517:prevention & control; D002340:Carotid Artery Diseases / Q000150:complications / Q000000981:diagnostic imaging / Q000601:surgery; D003399:Craniotomy; D019299:Decompression, Surgical; D005260:Female; D023261:Glasgow Outcome Scale; D006406:Hematoma / Q000000981:diagnostic imaging / Q000209:etiology / Q000601:surgery*; D006801:Humans; D002532:Intracranial Aneurysm / Q000150:complications / Q000000981:diagnostic imaging / Q000601:surgery*; D019586:Intracranial Hypertension / Q000517:prevention & control; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D012720:Severity of Illness Index; D013345:Subarachnoid Hemorrhage / Q000000981:diagnostic imaging / Q000209:etiology / Q000601:surgery*; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D020301:Vasospasm, Intracranial / Q000517:prevention & control